Consensus process to develop a best-practice document on the role of chiropractic care in health promotion, disease prevention, and wellness

Prevention-Focused Care: The Potential Role of Chiropractors in Hong Kong’s Primary Healthcare Transformation

Hong Kong's healthcare system is moving toward preventive and primary care to address the complicated demands of the aging population. Chiropractic professionals are in an advantageous position to support a prevention-focused strategy by identifying musculoskeletal problems early, reducing risks, and promoting healthy lifestyles. This article examines how the involvement of chiropractors in public health programs could improve population health in Hong Kong and boost primary care. The inclusion of chiropractors in district health centers and other initiatives would offer safer and more cost-effective choices for treating functional problems and chronic pain. Chiropractors should be involved in policymakers' attempts to create a sustainable healthcare system that meets Hong Kong's long-term healthcare requirements.

Reframing a debate in chiropractic

The chiropractic profession is 125 years old and has evolved a culture beset with internal conflict. The internal ructions have been particularly noticeable during the last 20 years. The recent resignation of the entire World Federation of Chiropractic Research Committee has again focussed the conflicting views and goals of the “wellness” and “evidence” factions within the profession. These polarising viewpoints are worsening to the degree that there are calls for the profession to break into two separate entities. Key to the recognition of the differences within the profession is the recognition of title for particular sub populations of patients presenting to chiropractors. For many of the sub populations such as sport or paediatrics there has grown appropriate post professional specialist educational training sometimes leading to a protected title. However, this is not occurring in that group of practitioners that choose to focus on wellness care. A recommendation is made that wellness chiropractic be viewed as a post professional specialty program within chiropractic, as it is in medicine and elsewhere, and that recognition follow after appropriate post professional educational programs have been completed, as is customary in the other special interest groups. In order to do so, consensus will be required from all stakeholders within the profession on the level, scope and depth of such programs. Furthermore, it is possible that different jurisdictions around the world may require different post graduate educational levels based on local competitive, legal and professional circumstances. In such cases, transitioning to the higher level over a period of time may be undertaken. Recognition of the wellness specialty by the profession would allow for vertical integration with other healthcare providers as well as help bridge a gap between the entrepreneur and academic groups that would be responsible for creating these programs at tertiary education institutions. Finally, should these programs acquire evidence to underpin them, a process that would be taught within the programs, it is likely that recognition of an extended scope of practice would occur increasing the appeal of chiropractic to the public.

The Role of Chiropractic Care in Providing Health Promotion and Clinical Preventive Services for Adult Patients with Musculoskeletal Pain: A Clinical Practice Guideline

Objective: To develop evidence-based recommendations on best practices for delivery of clinical preventive services by chiropractors and to offer practical resources to empower provider applications in practice. Design: Clinical practice guideline based on evidence-based recommendations of a panel of practitioners and experts on clinical preventive services. Methods: Synthesizing the results of a literature search for relevant clinical practice guidelines and systematic reviews, a multidisciplinary steering committee with training and experience in health promotion, clinical prevention, and/or evidence-based chiropractic practice drafted a set of recommendations. A Delphi panel of experienced practitioners and faculty, primarily but not exclusively chiropractors, rated the recommendations by using the formal consensus methodology established by the RAND Corporation/University of California. Results: The Delphi consensus process was conducted during January-February 2021. The 65-member Delphi panel reached a high level of consensus on appropriate application of clinical preventive services for screening and health promotion counseling within the chiropractic scope of practice. Interprofessional collaboration for the successful delivery of clinical preventive services was emphasized. Recommendations were made on primary, secondary, tertiary, and quaternary prevention of musculoskeletal pain. Conclusions: Application of this guideline in chiropractic practice may facilitate consistent and appropriate use of screening and preventive services and foster interprofessional collaboration to promote clinical preventive services and contribute to improved public health.

Suicide prevention, public health, and the chiropractic profession: a call to action

BACKGROUND

Suicide is a major public health concern that has wide-reaching implications on individuals, families, and society. Efforts to respond to a public health concern as a portal-of-entry provider can reduce morbidity and mortality of patients. The objective of this commentary is a call to action to initiate dialogue regarding suicide prevention and the role the chiropractic profession may play.

DISCUSSION

This public health burden requires doctors of chiropractic to realize current strengths and recognize contemporaneous deficiencies in clinical, research, and policy environments. With this better understanding, only then can the chiropractic profession strive to enhance knowledge and promote clinical acumen to target and mitigate suicide risk to better serve the public.

CONCLUSION

We implore the profession to transition from bystander to actively engaged in the culture of suicide prevention beholden to all aspects of the biopsychosocial healthcare model. The chiropractic profession's participation in suicide prevention improves the health and wellness of one's community while also impacting the broader public health arena.

Active Long-term Care Strategies in a Group Setting for Chronic Spine Pain in 3 United States Military Veterans: A Case Series

Objective

The purpose of this article is to describe the management of chronic spine pain in 3 United States military veterans who participated in extended courses of chiropractic care that focused on active care strategies in a group setting.

Clinical Features

A 68-year old male veteran (case 1) with a 90% service-connected disability rating presented with chronic neck and lower back pain. An 82-year old male veteran (case 2) with a 20% service-connected disability rating presented with chronic neck and upper back pain. A 66-year old male veteran (case 3) presented with a 10% service-connected disability with chronic episodic back and neck pain. Each veteran described a desire to maintain ongoing chiropractic treatments after completion of a course of chiropractic care in which maximal therapeutic gain had been determined. Patient-Reported Outcomes Measurement Information System (PROMIS) Patient Interference Short Form 6b (PPI), PROMIS Physical Function Short Form 10b (PPF), and Pain, Enjoyment, and General Activity (PEG) outcome measurement tools were used to track response to care.

Interventions and Outcome

Each veteran participated in an extended course of chiropractic visits consisting of group pain education, group cognitive behavioral strategies, group exercise, group mind-body self-regulation therapy, and optional individual manual therapy. Case 1 completed 8 extended chiropractic visits in 12 months and reported no change in PPI scores, improvement in PPF scores, and worsening PEG scores. Cases 2 and 3 completed 6 extended chiropractic visits each over a 12-month period and reported improvements in PPI, PPF, and PEG scores.

Conclusion

This article describes the responses of 3 veterans with chronic spine pain participating in long-term care using chiropractic visits in a group setting that focused on active care strategies. Our group-based, active care approach differs from those described in literature, which commonly focus on visits with a strong emphasis on manual therapy in 1-on-1 patient encounters.

Chiropractic Day: A Historical Review of a Day Worth Celebrating

OBJECTIVE

The purpose of this paper is to review and discuss historical concepts about the celebration of Chiropractic Day.

DISCUSSION

Daniel David Palmer attributed September 18, 1895 to be the day that he delivered the first chiropractic adjustment. As the chiropractic profession grew, the celebration of Chiropractic Day became more widespread throughout the United States and the world. This paper offers suggestions about how to celebrate Chiropractic Day. Activities include educating, learning, honoring, volunteering, and engaging.

CONCLUSION

The chiropractic profession celebrates its birth on September 18. Regardless of the many different names used over the past 125 years, including Chiropractic Founder's Day, Chiropractic Rally Day, Chiropractic Anniversary, and Chiropractic Discovery Day, the celebration of this special day provides an opportunity to reflect on how far the profession has come and how chiropractors continue to help and serve their patients.

Development of a Clinical Decision Aid for Chiropractic Management of Common Conditions Causing Low Back Pain in Veterans: Results of a Consensus Process

OBJECTIVE

The purpose of this study was to develop a clinical decision aid for chiropractic management of common conditions causing low back pain (LBP) in veterans receiving treatment in US Veterans Affairs (VA) health care facilities.

METHODS

A consensus study using an online, modified Delphi technique and Research Electronic Data Capture web application was conducted among VA doctors of chiropractic. Investigators reviewed the scientific literature pertaining to diagnosis and treatment of nonsurgical, neuromusculoskeletal LBP. Thirty seed statements summarizing evidence for chiropractic management, a graphical stepped management tool outlining diagnosis-informed treatment approaches, and support materials were then reviewed by an expert advisory committee. Email notifications invited 113 VA chiropractic clinicians to participate as Delphi panelists. Panelists rated the appropriateness of the seed statements and the stepped process on a 1-to-9 scale using the RAND/University of California, Los Angeles methodology. Statements were accepted when both the median rating and 80% of all ratings occurred within the highly appropriate range.

RESULTS

Thirty-nine panelists (74% male) with a mean (standard deviation) age of 46 (11) years and clinical experience of 17 (11) years participated in the study. Accepted statements addressed included (1) essential components of chiropractic care, (2) treatments for conditions causing or contributing to LBP, (3) spinal manipulation mechanisms, (4) descriptions and mechanisms of commonly used chiropractic interventions, and (5) a graphical stepped clinical management tool.

CONCLUSION

This study group produced a chiropractic clinical decision aid for LBP management, which can be used to support evidence-based care decisions for veterans with LBP.

Chiropractors' Perspectives on the Meaning and Assessment of Quality of Life Within Their Practice in New Zealand: An Exploratory Qualitative Study

OBJECTIVE

The purpose of this study was to gain an understanding on what quality of life (QOL) and its assessment means to chiropractors in everyday practice.

METHODS

This study captured chiropractors' perspectives on the QOL construct and its assessment using a qualitative descriptive methodology that comprised 2 focus groups, each with 4 participants using semi-structured, open-ended questioning. Participants from Aotearoa, New Zealand, were also asked to evaluate 4 QOL patient-reported outcome measurements from a clinical perspective.

RESULTS

Two of the participants were faculty at the New Zealand College of Chiropractic, 5 were in full-time practice, and 1 was practicing part time. Using qualitative content analysis, 3 main themes were identified. These chiropractors perceived that patients have misconceptions about how chiropractic can affect QOL. They lacked clarity in communicating QOL and its related concepts to establish a clinically meaningful patient encounter. Finally, there is uncertainty in how and when to measure QOL, which appears to affect how they discuss and assess QOL in practice.

CONCLUSION

There is a complex combination of factors that makes communication regarding QOL challenging. This exploratory qualitative study helps to understand the challenges faced in how and when to communicate and assess QOL more effectively in chiropractic practice.

Chiropractic Integrated Care Pathway for Low Back Pain in Veterans: Results of a Delphi Consensus Process

OBJECTIVE

The purpose of this study was to develop an integrated care pathway for doctors of chiropractic, primary care providers, and mental health professionals who manage veterans with low back pain, with or without mental health comorbidity, within Department of Veterans Affairs health care facilities.

METHODS

The research method used was a consensus process. A multidisciplinary investigative team reviewed clinical guidelines and Veterans Affairs pain and mental health initiatives to develop seed statements and care algorithms to guide chiropractic management and collaborative care of veterans with low back pain. A 5-member advisory committee approved initial recommendations. Veterans Affairs-based panelists (n = 58) evaluated the pathway via e-mail using a modified RAND/UCLA methodology. Consensus was defined as agreement by 80% of panelists.

RESULTS

The modified Delphi process was conducted in July to December 2016. Most (93%) seed statements achieved consensus during the first round, with all statements reaching consensus after 2 rounds. The final care pathway addressed the topics of informed consent, clinical evaluation including history and examination, screening for red flags, documentation, diagnostic imaging, patient-reported outcomes, adverse event reporting, chiropractic treatment frequency and duration standards, tailored approaches to chiropractic care in veteran populations, and clinical presentation of common mental health conditions. Care algorithms outlined chiropractic case management and interprofessional collaboration and referrals between doctors of chiropractic and primary care and mental health providers.

CONCLUSION

This study offers an integrative care pathway that includes chiropractic care for veterans with low back pain.

Understanding patient profiles and characteristics of current chiropractic practice: a cross-sectional Ontario Chiropractic Observation and Analysis STudy (O-COAST)

OBJECTIVES

There is no current detailed profile of people seeking chiropractic care in Canada. We describe the profiles of chiropractors' practice and the reasons, nature of the care provided to their patients and extent of interprofessional collaborations in Ontario, Canada.

DESIGN

Cross-sectional observational study.

SETTING

Primary care setting in Ontario, Canada.

PARTICIPANTS

We randomly recruited chiropractors from a list of registered chiropractors (n=3978) in active practice in 2015. Of the 135 randomly selected chiropractors, 120 were eligible, 43 participated and 42 completed the study.

OUTCOME MEASURES

Each chiropractor recorded information for up to 100 consecutive patient encounters, documenting patient health profiles, reasons for encounter, diagnoses and care provided. Descriptive statistics summarised chiropractor, patient and encounter characteristics, with analyses accounting for clustering and design effects.

RESULTS

Chiropractors provided data on 3523 chiropractor-patient encounters. More than 65% of participating chiropractors were male, mean age 44 years and had practised on average 15 years. The typical patient was female (59% of encounters), between 45 and 64 years (43%) and retired (21%) or employed in business and administration (13%). Most (39.4%) referrals were from other patients, with 6.8% from physicians. Approximately 68% of patients paid out of pocket or claimed extended health insurance for care. Most common diagnoses were back (49%, 95% CI 44 to 56) and neck (15%, 95% CI 13 to 18) problems, with few encounters related to maintenance/preventive care (0.86%, 95% CI 0.2 to 3.9) and non-musculoskeletal problems (1.3%, 95% CI 0.7 to 2.3). The most common treatments included spinal manipulation (72%), soft tissue therapy (70%) and mobilisation (35%).

CONCLUSIONS

This is the most comprehensive profile to date of chiropractic practice in Canada. People who present to Ontario chiropractors are mostly adults with a musculoskeletal condition. Our results can be used by stakeholders to make informed decisions about workforce development, education and healthcare policy related to chiropractic care.

Chronic Progressive External Ophthalmoplegia and Bilateral Vestibular Hypofunction: Balance, Gait, and Eye Movement Before and After Multimodal Chiropractic Care: A Case Study

Objective

The purpose of this report is to describe care of a patient with chronic progressive external ophthalmoplegia and bilateral vestibular hypofunction.

Clinical Features

A 66-year-old patient presented with limited eye movement and mild ptosis, which led to a diagnosis of chronic progressive external ophthalmoplegia. Rotary chair testing suggested vestibular involvement. Other symptoms included dizziness, problems with balance, and chronic stiffness in his cervical and thoracic regions. He had anxiety about loss of function and limited exercise habits because of fear of falling. Examination methods included balance assessment, kinetic aspects of walking, and videonystagmography.

Intervention and Outcome

He had already begun regular practice of vestibular rehabilitation exercises before receiving 18 sessions of manual and instrument-assisted chiropractic manipulation, along with mobilization, stretching, and transverse massage, over 37 weeks. In addition to self-reported improvements, there was substantially decreased postural sway during balance assessment and there were small improvements in eye movement, ptosis, and walking.

Conclusion

This patient showed improvements in balance, eye movements, and walking while undergoing multimodal chiropractic care and practicing eye and balance exercises.

The prevalence and determinants of physical activity promotion by Australian chiropractors: A cross sectional study

BACKGROUND

Approximately one in four adults do not meet the World Health Organisation physical activity recommendations. While health promotion (i.e., physical activity) is common within chiropractic settings, little is known about chiropractors discussing this public health issue with their patients. The aim of our study is to examine the prevalence and characteristics of Australian chiropractors who frequently discuss patient physical activity.

METHODS

A national cross-sectional survey of chiropractors focusing upon practitioner characteristics, practice settings and clinical management characteristics. Regression analyses were conducted on 1924 survey respondents to identify factors associated with practitioners who frequently discuss physical activity with patients.

RESULTS

Eighty-five percent of Australian chiropractors reported 'often' discussing physical activity as part of their patient management. The strongest factors associated with chiropractors who frequently discuss physical activity obtained from the multivariate analysis include: often discussing occupational health and safety (odds ratio [OR] = 6.10; 95%CI: 3.88, 9.59), often discussing diet/nutrition (OR = 4.56; 95%CI: 3.12, 6.66), often discussing smoking/drugs/alcohol (OR = 4.41; 95%CI: 2.06, 9.40), often use of specific exercise therapy/rehabilitation/injury taping (OR = 3.76; 95%CI: 2.62, 5.39) and often caring for athletes or sports people (OR = 2.18; 95%CI: 1.56, 3.06) within their practice setting.

CONCLUSION

Discussing physical activity is a frequent feature of patient management among most chiropractors in Australia. The association between these practitioners and discussion of other costly public health burdens could suggest chiropractors have a valuable role to play in chronic disease prevention. Given the growing need for practitioner-led promotion of patient physical activity further research examination of the role and contribution of chiropractors in promoting this important public health topic among patients and communities is needed.

The treatment of migraine patients within chiropractic: analysis of a nationally representative survey of 1869 chiropractors

BACKGROUND

While the clinical role of manual therapies in migraine management is unclear, the use of chiropractors for this condition is considerable. The aim of this study is to evaluate the prevalence and characteristics of chiropractors who frequently manage patients with migraine.

METHODS

A national cross-sectional survey of chiropractors collected information on practitioner characteristics, clinical management characteristics and practice settings. A secondary analysis was conducted on 1869 respondents who reported on their migraine caseload to determine the predictors associated with the frequent management of patients with migraine.

RESULTS

A large proportion of chiropractors report having a high migraine caseload (HMC) (n = 990; 53.0%). The strongest factors predicting a chiropractor having a HMC include the frequent treatment of patients with axial neck pain (OR = 2.89; 95%CI: 1.18, 7.07), thoracic pain (referred/radicular) (OR = 2.52; 95%CI: 1.58, 3.21) and non-musculoskeletal disorders (OR = 3.06; 95%CI: 2.13, 4.39).

CONCLUSIONS

Several practice-setting and clinical management characteristics are associated with chiropractors managing a HMC. These findings raise key questions about the therapeutic approach to chiropractic migraine management that deserves further examination. There is a need for more primary research to assess the approach to headache and migraine management provided by chiropractors and to understand the prevalence, burden and comorbidities associated with migraine found within chiropractic patient populations. This information is vital in helping to inform safe, effective and coordinated care for migraine sufferers within the wider health system.

On-Site Chiropractic Care as an Employee Benefit: A Single-Location Case Study

Objective

The purpose of this report is to describe the role of on-site chiropractic care in one corporate environment.

Methods

A part-time chiropractic practice that provides services to a single company on site, 1 day per week, is described. Most care is oriented toward "wellness," is paid for by the employer, and is limited only by the chiropractor's few weekly hours of on-site availability. With approval from the company, the authors conducted an absenteeism analysis after obtaining ethics approval and consent from employee-patients who received care between 2012 and 2014. Comparisons of absenteeism rates of the sample were compared with lost worktime rates from the US Bureau of Labor Statistics' Labor Force Statistics.

Results

Of 40 current employees, 35 used chiropractic services; 17 employee-patients met the inclusion criteria. The lost worktime rates of those using chiropractic services (0.72%, 0.55%, and 0.67%, for 2012, 2013, and 2014, respectively) were lower than corresponding rates from Labor Force Statistics (1.5%, 1.2%, and 1.1%).

Conclusions

Absenteeism for the employee-patients was lower than equivalent national figures in this sample of workers. Though these results may or may not be related to the chiropractic care, these findings prompt further investigation into this relationship.

Functional disability in patients with low back pain: the mediator role of suffering and beliefs about pain control in patients receiving physical and chiropractic treatment

•

Subjective suffering mediated the relationship between depression and functional disability regardless of the type of treatment.

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Beliefs about chance events mediated the relationship between depression and functional disability only in the physical therapy treatment.

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Intervention should target cognitive and psychological factors in LBP patients.

Background

Low back pain is the leading cause of disability worldwide. There is evidence that depression, anxiety, and external locus of control are negative predictors of functional disability in low back patients.

Methods

This study focused on the mediator role of suffering and beliefs about pain control in the relationship between psychological morbidity and functional disability in patients receiving physical therapy and chiropractic treatment for chronic low back pain. The sample included 213 patients receiving chiropractic treatment and 125 receiving physical therapy, who answered the following instruments: Beliefs about Pain Control Questionnaire; Inventory of Subjective Experiences of Suffering in Illness; Oswestry Low Back Pain Disability Questionnaire; and the Hospital Anxiety and Depression Scales.

Results

Suffering was a mediator in the relationship between depression and functional disability in both treatment groups. Only beliefs related to external chance events mediated the relationship between depression and functional disability in the physical therapy group, but not in the chiropratic teratment group.

Conclusion

Intervention should focus on suffering regardless of the type of treatment and target beliefs about pain control, in patients receiving physical therapy treatment since they seem to play a key role in functional disability in patients with low back pain.

The biopsychosocial model and chiropractic: a commentary with recommendations for the chiropractic profession

There is an increasing awareness, interest and acceptance of the biopsychosocial (BPS) model by all health care professionals involved with patient care. The areas of spine care and pain medicine are no exception, and in fact, these areas of health care are a major centerpiece of the movement from the traditional biomedical model to a BPS model of patient assessment and delivery of care. The chiropractic approach to health care has a history that is grounded in key aspects of the BPS model. The profession has inherently implemented certain features of the BPS model throughout its history, perhaps without a full understanding or realization. The purpose of this paper is to present an overview of the BPS model, its relationship with spine care and pain management, and to discuss the BPS model, particularly psychosocial aspects, in the context of its historical relationship with chiropractic. We will also provide recommendations for the chiropractic profession as it relates to successful adoption of a full integration of the BPS model.

Primary prevention in chiropractic practice: a systematic review

Background

Chiropractors are primarily concerned with musculoskeletal disorders but have the responsibility to deal also with prevention in other areas.

Objectives

To establish the prevalence of chiropractors who have a positive opinion on the use of primary prevention (PP), their actual use of PP, and the proportion of patients who consult for PP in relation to (i) musculoskeletal disorders, (ii) public health issues, or (iii) chiropractic treatment for wellness.

Method

A systematic search for literature was done using PubMed, Embase, Index to Chiropractic Literature, and Google Scholar and updated on February 15th 2017. Inclusion criteria were: surveys on chiropractors and/or chiropractic patients, information had to be present on PP in relation to the percentage of patients who consult for PP in chiropractic practice or in a chiropractic student clinic, and/or the percentage of chiropractors who reported using PP, and/or information on chiropractors’ opinions of the use of PP, in the English, French, or Scandinavian languages. The review followed the PRISMA guidelines. Articles were classified as ‘good’, ‘acceptable’ and ‘unacceptable’ based on scores of quality items. Results from the latter group were not taken into account.

Results

Twenty-five articles were included, reporting on twenty-six studies, 19 of which dealt with wellness. The proportion of chiropractors who stated that they had a positive opinion on PP was generally higher than the proportion of chiropractors offering PP. Most chiropractors offered some type of PP for musculoskeletal disorders and more than a half stated that they did so in the public health area but also for wellness. For all types of PP, however, it was rarely stated to be the reason for patients consulting. Regardless the type of PP, the proportion of patients who actually consulted specifically for PP was much smaller than the proportion of chiropractors offering PP.

Conclusion

More research efforts have been put into wellness than into prevention of musculoskeletal disorders or public health-related disorders. It therefore seems that parts of the chiropractic profession are in search of an understanding of various aspects of clinical practice over and above its traditional musculoskeletal role. Interestingly, only a small proportion of chiropractic patients consult for PP, despite the readiness of the profession to offer such services.

Training chiropractic students in weight management counseling using standardized patients

OBJECTIVE

The aim of this study was to describe and assess an activity that trained chiropractic students to counsel patients on weight management through the use of standardized patients.

METHODS

This was a descriptive study using mixed methods. Students were trained to apply health behavior theory and the transtheoretical model. Standardized patients were given a case to portray with the students. Students had 15 minutes for the encounter. The encounters were assessed in 2 ways: (1) standardized patients answered a brief questionnaire about the students' performance, and (2) students answered a questionnaire about the utility of the intervention. Numerical data were extracted from the audiovisual management platform, and statistics were computed for each question. Comments made by students and patients were transferred verbatim for content analysis.

RESULTS

A total of 102 students took part in the activity. Students' performance in the encounter was uniformly high, with over 90% "yes" responses to all questions except "gave me printed information material" and "discussed the printed material with me." The key issue identified in the comments by standardized patients was that students tended not to connect weight management with their chief complaint (low back pain). Nearly all students (97%) thought the activity would be useful to their future practice, and 97% felt it had increased their confidence in providing weight management counseling.

CONCLUSION

This experiential activity was assessed to be useful to students' future practice and appeared to provide them with skills to successfully communicate with patients on weight management.

The relationship between chiropractor required and current level of business knowledge

Background

Chiropractors frequently practice within health care systems requiring the business acumen of an entrepreneur. However, some chiropractors do not know the relationship between the level of business knowledge required for practice success and their current level of business knowledge. The purpose of this quantitative study was to examine the relationship between chiropractors’ perceived level of business knowledge required and their perceived level of current business knowledge.

Methods

Two hundred and seventy-four participants completed an online survey (Health Care Training and Education Needs Survey) which included eight key business items. Participants rated the level of perceived business knowledge required (Part I) and their current perceived level of knowledge (Part II) for the same eight items. Data was collected from November 27, 2013 to December 18, 2013. Data were analyzed using Spearman’s ranked correlation to determine the statistically significant relationships for the perceived level of knowledge required and the perceived current level of knowledge for each of the paired eight items from Parts I and II of the survey. Wilcoxon Signed Ranks Tests were performed to determine the statistical difference between the paired items.

Results

The results of Spearman’s correlation testing indicated a statistically significant (p < 0.01) positive correlation for the perceived level of knowledge required and perceived current level of knowledge for six variables: (a) organizational behavior, (b) strategic management, (c) marketing, (d) legal and ethical, (e) managerial decisions, and (f) operations. Wilcoxon Signed Ranks testing indicated a significant difference for three paired items: strategic management; marketing and; legal and ethical. The results suggest that relationships exist for the majority of business items (6 of 8) however a statistically difference was demonstrated in only three of the paired business items.

Conclusion

The implications of this study for social change include the potential to improve chiropractors’ business knowledge and skills, enable practice success, enhance health services delivery and positively influence the profession as a viable career.

A workforce survey of Australian chiropractic: the profile and practice features of a nationally representative sample of 2,005 chiropractors

Background

This paper reports the profile of the Australian chiropractic workforce and characteristics of chiropractic care from a large nationally-representative sample of practitioners.

Methods

A 21-item questionnaire examining practitioner, practice and clinical management characteristics was distributed to all registered chiropractors (n = 4,684) in Australia in 2015 via both online and hard copy mail out.

Results

The survey attracted a response rate of 43% (n = 2,005), and the sample is largely representative of the national chiropractic workforce on a number of key indicators. The average age of the chiropractors was 42.1 years, nearly two-thirds are male, and the vast majority hold a bachelor degree or higher qualification. Australian chiropractors are focused upon treating people across a wide age range who mainly present with musculoskeletal conditions. Australian chiropractors have referral relationships with a range of conventional, allied health and complementary medicine (CAM) providers.

Conclusion

The chiropractic profession represents a substantial component of the contemporary Australian health care system with chiropractors managing an estimated 21.3 million patient visits per year. While the Australian chiropractic workforce is well educated, research engagement and research capacity remains sub-optimal and there is much room for further capacity building to help chiropractic reach full potential as a key integrated profession within an evidence-based health care system. Further rich, in-depth research is warranted to improve our understanding of the role of chiropractic within the Australian health care system.

Chiropractic Identity: A Neurological, Professional, and Political Assessment

OBJECTIVE

The purpose of this article is to propose a focused assessment of the identity of chiropractic and its profession, triangulating multiple viewpoints converging upon various aspects and definitions of neurology, manual medicine, and alternative or mainstream medicine.

DISCUSSION

Over 120 years since its inception, chiropractic has struggled to achieve an identity for which its foundations could provide optimal health care. Despite recognition of the benefits of spinal manipulation in various government guidelines, advances in US military and Veterans Administration, and persistently high levels of patient satisfaction, the chiropractic profession remains underrepresented in most discussions of health care delivery. Distinguishing characteristics of doctors of chiropractic include the following: (1) they embrace a model of holistic, preventive medicine (wellness); (2) they embrace a concept of neurological imbalance in which form follows function, disease follows disturbed biochemistry, and phenomenology follows physiology; (3) they diagnose, and their institutions of training are accredited by a body recognized by the US Department of Education; (4) they manage patients on a first-contact basis, often as primary care providers in geographical areas that are underserved; (5) the spine is their primary-but not exclusive-area of interaction; (6) they deliver high-velocity, low-amplitude adjustments with a superior safety record compared with other professions; and (7) they use a network of institutions worldwide that have shown increasing commitments to research.

CONCLUSION

This article provides an overview of chiropractic identity from 6 points of view: (1) concepts of manual medicine; (2) areas of interest beyond the spine; (3) concepts of the chiropractic subluxation; (4) concepts of neurology; (5) concepts of mainstream or alternative health care; and (6) concepts of primary care, first-contact provider, or specialist.

Outcomes of a pilot study in chiropractic practices in Western Australia

BACKGROUND

This paper reports the quantitative outcomes of a mixed-methods pilot study of the characteristics and demographics of chiropractic practices and patients in Western Australia.

METHODS

This was a mixed-methods data transformation model (qualitative to quantitative) pilot study. A non-random sample of chiropractic practices across Western Australia was recruited and data collected anonymously from consecutive new patients using an online platform. Data covered practice and patient demographics and characteristics, alongside quality of life measures. A descriptive quantitative analysis characterised the sample, and the patient population was stratified by main reason for presentation to compare characteristics according to the presence of secondary complaints. Odds ratios were calculated to estimate the odds of a secondary complaint for various combinations of main complaints, from univariate logistic regression models.

RESULTS

Of the 539 registered practitioners in WA in July 2014, 33 agreed to participate, from 20 different practices. Ten participating practices provided data on 325 adult new patients. The recruited practices (metropolitan n = 8, regional n = 2) had a positive response rate of 79.7 % (n = 301 metropolitan and n = 24 regional patients), mean age 36.3 years (range 18-74) (53.2 % female). Spinal problems were reported as the main reason for consultation by 67 % and as secondary reasons by 77.2 % of patients. People presented primarily for health maintenance or a general health check in 11.4 %, and as a secondary reason 14.8 %. There were 30 % of people below societal norms for the SF-12 Physical Component Score (mean 47.19, 95 % CI; 46.27-48.19) and 86 % for the Mental Component Score (mean 36.64, 95 % CI; 35.93-37.65), Pain Impact Questionnaire mean scores were 54.60 (95 % CI; 53.32-55.88).

CONCLUSIONS

Patients presented to chiropractors in Western Australia with a fairly wide range of conditions, but primarily spinal and musculoskeletal-related problems. A significant proportion of patients had associated, or found to be at risk of, depression. Consequently, there are responsibilities and opportunities for chiropractors with respect to providing care services that include health promotion and well-being education related to musculoskeletal/spinal and mental health. This pilot study supports the feasibility of a future confirmatory study where the potential role of chiropractors in spinal/musculoskeletal health management may be explored.

TRIAL REGISTRATION

ACTRN12616000434493: Australian New Zealand Clinical Trials Registry (ANZCTR), Registered 5 April 2016, First participant enrolled 01 July 2014 Retrospectively Registered.

Chiropractic intern attitudes, beliefs, and future practice intentions with regard to health promotion, wellness, and preventive services

OBJECTIVE

This pilot study explored the attitudes, beliefs, and intentions of a group of chiropractic interns concerning health promotion, wellness, and preventive services before and after a series of brief educational interventions.

METHODS

Interns completed a survey before (n = 37) and after (n = 22) the interventions. The survey included 12 Likert scale questions about attitudes and intentions toward wellness and health promotion models. The interventions consisted of classroom lectures, clinical training, and online information pertaining to health promotion and wellness.

RESULTS

The interns initially favored wellness models, perceived a need for them, and felt partially prepared to administer them, with mean Likert scores 4 or greater on a 1 to 5 scale. Afterward, the average scores were higher and the interns reported some benefit from this short course of training.

CONCLUSION

The initial survey demonstrated that interns had some understanding of wellness, health promotion, and preventive services, and favored utilization of these services. The follow-up survey suggested that a short educational intervention could have a positive impact on these attitudes and future utilization of wellness procedures in their practices.

The Physiological Role of Tumor Necrosis Factor in Human Immunity and Its Potential Implications in Spinal Manipulative Therapy: A Narrative Literature Review

OBJECTIVE

Although tumor necrosis factor (TNF) is a well-known inflammatory cytokine in the pathological development of various human diseases, its physiological roles are not widely understood nor appreciated. The molecular mechanisms underlying spinal manipulation therapy (SMT) remain elusive. The relationship between TNF and SMT is unclear. Thus, we performed this literature review to better understand TNF physiology and its potential relationship with SMT, and we propose a novel mechanism by which SMT may achieve clinical benefits by using certain beneficial features of TNF.

METHODS

We searched several databases for relevant articles published between 1975 and 2015 and then reexamined the studies from current immunophysiological perspectives.

RESULTS

The history and recent progresses in TNF physiology research were explored. Conflicting reports on the relationship between TNF and SMT were identified. Based on the newly discovered interaction between TNF and regulatory T cells, we proposed a putative biphasic TNF response to SMT, which may resolve the conflicts in the reported observations and interpretations.

CONCLUSION

The current literature about TNF informed our discussion of new physiological roles for TNF, which may help to better understand the physiological effects of SMT.

Who consults chiropractors in Victoria, Australia?: Reasons for attending, general health and lifestyle habits of chiropractic patients

Background

COAST (Chiropractic Observational and Analysis STudy) reported the clinical practices of chiropractors. The aims of this study were to: 1) describe the chiropractic patient demographic and health characteristics; 2) describe patient-stated reasons for visiting a chiropractor; 3) describe chiropractic patient lifestyle characteristics; 4) compare, where possible, chiropractic patient characteristics to the general Australian population.

Methods

Fifty-two chiropractors in Victoria, Australia, provided information for up to 100 consecutive encounters. If patients attended more than once during the 100 encounters, only data from their first encounter were included in this study. Where possible patient characteristics were compared with the general Australian population.

Results

Data were collected from December 2010 to September 2012. Data were provided for 4464 encounters, representing 3287 unique individuals. The majority of chiropractic encounters were for musculoskeletal conditions or for wellness/maintenance. The majority of patient comorbidities were musculoskeletal, circulatory or endocrine/metabolic in nature. Eight hundred chiropractic patients (57 %, 95 % CI: 53–61) described their self-reported health as excellent or very good and 138 patients (10 %, 95 % CI: 8–12) as fair or poor. Seventy-one percent of adult male patients (18 years and older), and 53 % of adult female patients, were overweight or obese. Fourteen percent (n = 188, 95 % CI: 12–16) were current smokers and 27 % (n = 359, 95 % CI: 24–31) did not meet Australian alcohol consumption guidelines. Less than half of the chiropractic patients participated in vigorous exercise at least twice per week. Approximately 20 % ate one serving of vegetables or less each day, and approximately 50 % ate one serve of fruit or less each day. Compared to the general Australian population, chiropractic patients were less likely to smoke, less likely to be obese and more likely to describe their health in positive terms. However, many patients were less likely to meet alcohol consumption guidelines, drinking more than is recommended.

Conclusions

In general, chiropractic patients had more positive health and lifestyle characteristics than the Australian population. However, there were a significant proportion of chiropractic patients who did not meet guideline recommendations about lifestyle habits and there is an opportunity for chiropractors to reinforce public health messages with their patients.

Tobacco Cessation Training for Complementary and Alternative Medicine Practitioners: Results of a Practice-Based Trial

INTRODUCTION

Brief behavioral intervention (BI) is a tobacco-cessation best practice well established among conventional healthcare practitioners. Complementary and alternative medicine (CAM) practitioners treat significant numbers of tobacco users, but do not systematically receive BI training. The CAM Reach study developed and evaluated a tobacco cessation BI training program/practice system intervention adapted specifically for CAM practitioners, and evaluated in real-world CAM practices.

STUDY DESIGN

Single-arm intervention. Data were collected in 2010-2014 and analyzed in 2015.

SETTING/PARTICIPANTS

Private practices of 30 chiropractors, 27 acupuncturists, 42 massage therapists (N=99), in metropolitan Tucson, Arizona.

INTERVENTION

Eight-hour tobacco cessation BI continuing education workshop, in-office BI skills practice/assessment, and system intervention. Training tailored to the CAM practice setting addressed tobacco cessation best practices from the U.S. Public Health Service Guidelines.

MAIN OUTCOME MEASURES

Seventeen items (assessing practitioner behavior, motivation, and self-efficacy with tobacco cessation) comprising three factors, Tobacco Cessation Activity, Tobacco Cessation Motivation, and Non-CAM Tobacco Cessation Comfort, were assessed at baseline and 3, 6, 9, and 12 months post-training by practitioner self-report. Research staff visited practices at approximately the same intervals to directly observe changes in clinical practice systems.

RESULTS

At 3 months, there were significant increases in practitioners' tobacco cessation activities, motivation and confidence in helping patients quit tobacco, and comfort with providing information and referrals for guideline-based tobacco cessation aids (p<0.0001). Practitioners significantly increased rates of discussing cessation medications with patients (AOR=3.76, 95% CI=1.84, 7.68), and routinely asking about tobacco use in clinical practice (AOR=2.62, 95% CI=1.11, 6.20). Increases occurred across all three practitioner types and were sustained at 12 months-despite heterogeneity in professional training, practice patterns/organization, and practice business models.

CONCLUSIONS

Results suggest CAM practitioners are willing and able to offer BIs, and are an important, yet overlooked channel for promoting tobacco cessation and use of evidence-based cessation aids.

Chiropractic Attitudes and Utilization of Evidence-Based Practice: The Use of the EBASE Questionnaire

AIM

To examine the attitudes and utilization of evidence-based practice by chiropractors.

METHODS

Utilizing a descriptive survey implemented as an online questionnaire, we examined chiropractors׳ perception, skills, and level of training, their engagement in, the barriers and facilitators to, and possible interventions to evidence-based practice.

RESULTS

A total of 162 of 500 chiropractors completed the survey, providing a response rate of 32.4%. The majority of respondents were 30-39 years old, female, and worked in solo practice. A high proportion agreed/strongly agreed that evidence-based practice was necessary in the practice of chiropractic. Most respondents considered themselves to have above-average skills in locating professional literature, identifying answerable clinical questions, and identifying knowledge gaps in practice. However, many indicated receiving either no training or minimal education for conducting clinical research and systematic reviews and meta-analyses Most respondents had read or reviewed one to five professional articles and/or clinical research reports pertinent to their practice in the preceding month. Identified minor to moderate barriers to evidence-based practice were lack of time and lack of clinical evidence. Activities "very useful" in participating in evidence-based practice were access to free online databases and the ability to download full-text journal articles.

CONCLUSIONS

The responders of our survey embraced and considered themselves skillful in evidence-based practice. They utilized a number of resources to practice in such a manner and were not deterred by identified barriers. We support continued research in this field.

US chiropractors' attitudes, skills and use of evidence-based practice: A cross-sectional national survey

Background

Evidence based practice (EBP) is being increasingly utilized by health care professionals as a means of improving the quality of health care. The introduction of EBP principles into the chiropractic profession is a relatively recent phenomenon. There is currently a lack of information about the EBP literacy level of US chiropractors and the barriers/facilitators to the use of EBP in the chiropractic profession.

Methods

A nationwide EBP survey of US chiropractors was administered online (Nov 2012-Mar 2013) utilizing a validated self-report instrument (EBASE) in which three sub-scores are reported: attitudes, skills and use. Means, medians, and frequency distributions for each of the sub-scores were generated. Descriptive statistics were used to analyze the demographic characteristics of the sample. Means and proportions were calculated for all of the responses to each of the questions in the survey.

Results

A total of 1,314 US chiropractors completed the EBASE survey; the sample appeared to be representative of the US chiropractic profession. Respondents were predominantly white (94.3%), male (75%), 47 (+/− 11.6) years of age, and in practice for more than 10 years (60%). EBASE sub-score means (possible ranges) were: attitudes, 31.4 (8–40); skills, 44.3 (13–65); and use, 10.3 (0–24). Survey participants generally held favorable attitudes toward EBP, but reported less use of EBP. A minority of participants indicated that EBP coursework (17%) and critical thinking (29%) were a major part of their chiropractic education. The most commonly reported barrier to the use of EBP was “lack of time”. Almost 90% of the sample indicated that they were interested in improving their EBP skills.

Conclusion

American chiropractors appear similar to chiropractors in other countries, and other health professionals regarding their favorable attitudes towards EBP, while expressing barriers related to EBP skills such as research relevance and lack of time. This suggests that the design of future EBP educational interventions should capitalize on the growing body of EBP implementation research developing in other health disciplines. This will likely include broadening the approach beyond a sole focus on EBP education, and taking a multilevel approach that also targets professional, organizational and health policy domains.

Electronic supplementary material

The online version of this article (doi:10.1186/s12998-015-0060-0) contains supplementary material, which is available to authorized users.

Is There a Role for Complementary and Alternative Medicine in Preventive and Promotive Health? An Anthropological Assessment in the Context of U.S. Health Reform

Chronic conditions associated with lifestyle and modifiable behaviors are the leading causes of morbidity and mortality in the United States. The implementation of the Affordable Care Act offers an historic opportunity to consider novel approaches to addressing the nation's public health concerns. We adopt an anticipatory anthropological perspective to consider lifestyle behavior change as common ground shared by practitioners of both biomedicine and common forms of complementary and alternative medicine (CAM). At issue is whether CAM practitioners might play a more proactive and publicly endorsed role in delivering preventive and promotive health services to address these needs. Recognizing that this is a contentious issue, we consider two constructive roles for engaged medical anthropologists: (1) as culture brokers helping to facilitate interprofessional communities of preventive and promotive health practice and (2) in collaboration with health service researchers developing patient-near evaluations of preventive and promotive health services on patient well-being and behavior change.

Chiropractic Observation and Analysis Study (COAST): providing an understanding of current chiropractic practice

OBJECTIVES

COAST (Chiropractic Observation and Analysis Study) aimed to describe the clinical practices of chiropractors in Victoria, Australia.

DESIGN

Cross-sectional study using the BEACH (Bettering the Evaluation and Care of Health) methods for general practice.

SETTING AND PARTICIPANTS

180 chiropractors in active clinical practice in Victoria were randomly selected from the list of 1298 chiropractors registered on Chiropractors Registration Board of Victoria. Twenty-four chiropractors were ineligible, 72 agreed to participate, and 52 completed the study.

MAIN OUTCOME MEASURES

Each participating chiropractor documented encounters with up to 100 consecutive patients. For each chiropractor-patient encounter, information collected included patient health profile, patient reasons for encounter, problems and diagnoses, and chiropractic care.

RESULTS

Data were collected on 4464 chiropractor-patient encounters from 52 chiropractors between 11 December 2010 and 28 September 2012. In most (71%) encounters, patients were aged 25-64 years; 1% of encounters were with infants (age < 1 year; 95% CI, 0.3%-3.2%). Musculoskeletal reasons for encounter were described by patients at a rate of 60 per 100 encounters (95% CI, 54-67 encounters) and maintenance and wellness or check-up reasons were described at a rate of 39 per 100 encounters (95% CI, 33-47 encounters). Back problems were managed at a rate of 62 per 100 encounters (95% CI, 55-71 encounters). The most frequent care provided by the chiropractors was spinal manipulative therapy and massage.

CONCLUSIONS

A range of conditions are managed by chiropractors in Victoria, Australia, but most commonly these conditions are musculoskeletal-related. These results can be used by stakeholders of the chiropractic profession in workforce development, education and health care policy.

Weight gain as a consequence of living a modern lifestyle: a discussion of barriers to effective weight control and how to overcome them

OBJECTIVE

The purpose of this commentary is to discuss modern lifestyle factors that promote weight gain and to suggest methods for clinicians to more effectively educate patients about weight management.

DISCUSSION

Most adults in the United States are overweight or obese. Multiple factors related to the modern lifestyle appear to play causal roles. In general, the population maintains sedentary lives and overconsumes calorie-dense foods. In particular, refined carbohydrates negatively impact metabolism and stimulate neural addiction mechanisms, which facilitate weight gain. As adipose tissue mass accumulates, satiation centers in the hypothalamus become resistant to insulin and leptin, which leads to increased caloric consumption. Several behavior issues further augment weight gain, such as eating too quickly, a lack of sleep, high stress levels, and a lack of exercise. Finally, adipose tissue accumulation alters the body weight set point, which leads to metabolic changes that function to resist weight loss efforts. Each of these factors may work together to augment weight gain and promote obesity. Health care providers, such as chiropractic physicians, who educate patients on wellness, prevention, and lifestyle changes are well positioned to address these issues.

CONCLUSION

People need to be educated about the modern lifestyle factors that prevent effective weight management. Without this knowledge and the associated practical application of lifestyle choices that prevent weight gain, becoming overweight or obese appears to be an unavoidable consequence of living a modern lifestyle.

Beyond spinal manipulation: should Medicare expand coverage for chiropractic services? A review and commentary on the challenges for policy makers

OBJECTIVES

Private insurance plans typically reimburse doctors of chiropractic for a range of clinical services, but Medicare reimbursements are restricted to spinal manipulation procedures. Medicare pays for evaluations performed by medical and osteopathic physicians, nurse practitioners, physician assistants, podiatrists, physical therapists, and occupational therapists; however, it does not reimburse the same services provided by chiropractic physicians. Advocates for expanded coverage of chiropractic services under Medicare cite clinical effectiveness and patient satisfaction, whereas critics point to unnecessary services, inadequate clinical documentation, and projected cost increases. To further inform this debate, the purpose of this commentary is to address the following questions: (1) What are the barriers to expand coverage for chiropractic services? (2) What could potentially be done to address these issues? (3) Is there a rationale for Centers for Medicare and Medicaid Services to expand coverage for chiropractic services?

METHODS

A literature search was conducted of Google and PubMed for peer-reviewed articles and US government reports relevant to the provision of chiropractic care under Medicare. We reviewed relevant articles and reports to identify key issues concerning the expansion of coverage for chiropractic under Medicare, including identification of barriers and rationale for expanded coverage.

RESULTS

The literature search yielded 29 peer-reviewed articles and 7 federal government reports. Our review of these documents revealed 3 key barriers to full coverage of chiropractic services under Medicare: inadequate documentation of chiropractic claims, possible provision of unnecessary preventive care services, and the uncertain costs of expanded coverage. Our recommendations to address these barriers include the following: individual chiropractic physicians, as well as state and national chiropractic organizations, should continue to strengthen efforts to improve claims and documentation practices; and additional rigorous efficacy/effectiveness research and clinical studies for chiropractic services need to be performed. Research of chiropractic services should target the triple aim of high-quality care, affordability, and improved health.

CONCLUSIONS

The barriers that were identified in this study can be addressed. To overcome these barriers, the chiropractic profession and individual physicians must assume responsibility for correcting deficiencies in compliance and documentation; further research needs to be done to evaluate chiropractic services; and effectiveness of extended episodes of preventive chiropractic care should be rigorously evaluated. Centers for Medicare and Medicaid Services policies related to chiropractic reimbursement should be reexamined using the same standards applicable to other health care providers. The integration of chiropractic physicians as fully engaged Medicare providers has the potential to enhance the capacity of the Medicare workforce to care for the growing population. We recommend that Medicare policy makers consider limited expansion of Medicare coverage to include, at a minimum, reimbursement for evaluation and management services by chiropractic physicians.

A framework for chiropractic training in clinical preventive services

The 2010 Patient Protection and Affordable Care Act provides incentives for both patients and providers to engage in evidence-based clinical preventive services recommended by the United States Preventive Services Task Force (USPSTF). Depending upon the application of the new health care act, Doctors of Chiropractic (DC) may be considered to be covered providers of many of these services. It is therefore essential that DCs’ training prepare them to competently deliver them. The aim of this commentary is to describe a framework for training in clinical preventive services, based largely on the USPSTF recommendations, which could be readily integrated into existing DC educational programs.

Feasibility of using a standardized patient encounter for training chiropractic students in tobacco cessation counseling

Objective : Although tobacco cessation training is included in many health profession programs, it is not yet routinely incorporated into chiropractic education. The purpose of this study was to assess the feasibility of incorporating a problem-based learning tobacco cessation activity into a lecture course for chiropractic students. Methods : Seventy-two students were assigned to participate in two 1-hour lectures on health promotion counseling and tobacco cessation followed by an experiential student-driven lab session using standardized patients at various stages of dependency and willingness to quit. The intervention was based on the transtheoretic model and the "5 A's" of counseling (ask, advise, assess, assist, arrange). Outcomes were assessed via (1) questionnaires completed by the standardized patients regarding the students' use of the 5A's, and (2) questionnaires completed by the students using a 5-point Likert scale of "strongly disagree" to "strongly agree" on the acceptability of this method of learning. Descriptive statistics were computed. Results : Sixty-eight students (94%) completed the activity, spending a median of 2.5 minutes with patients. Over 90% addressed 4 of the 5A's: 99% asked patients if they were smokers; 97% advised them to quit; 90% assessed if they were willing to quit; and 99% offered assistance in quitting. Only 79% arranged a follow-up visit. Overall, students expressed a positive response to the experience; 81% said it increased their confidence in being able to advise patients, and 77% felt it would be valuable for use in their future practice. Conclusion : This active learning exercise appeared to be a feasible way to introduce tobacco counseling into the curriculum.

The Nordic maintenance care program: the clinical use of identified indications for preventive care

Background

Low back pain (LBP) is a prevalent condition and has been found to be recurrent and persistent in a majority of cases. Chiropractors have a preventive strategy, maintenance care (MC), aimed towards minimizing recurrence and progression of such conditions. The indications for recommending MC have been identified in the Nordic countries from hypothetical cases. This study aims to investigate whether these indications are indeed used in the clinical encounter.

Methods

Data were collected in a multi-center observational study in which patients consulted a chiropractor for their non-specific LBP. Patient baseline information was a) previous duration of the LBP, b) the presence of previous episodes of LBP and c) early improvement with treatment. The chiropractors were asked if they deemed each individual patient an MC candidate. Logistic regression analyses (uni– and multi-level) were used to investigate the association of the patient variables with the chiropractor’s decision.

Results

The results showed that “previous episodes” with LBP was the strongest predictor for recommending MC, and that the presence of all predictors strengthens the frequency of this recommendation. However, there was considerable heterogeneity among the participating chiropractors concerning the recommendation of MC.

Conclusions

The study largely confirms the clinical use of the previously identified indications for recommending MC for recurrent and persistent LBP. Previous episodes of LBP was the strongest indicator.